Provider Demographics
NPI:1023878006
Name:EBONY GODDESS TOUCH LLC
Entity type:Organization
Organization Name:EBONY GODDESS TOUCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:I
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-278-8706
Mailing Address - Street 1:4375 NOTTINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3421
Mailing Address - Country:US
Mailing Address - Phone:586-278-8706
Mailing Address - Fax:
Practice Address - Street 1:4375 NOTTINGHAM RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-3421
Practice Address - Country:US
Practice Address - Phone:586-278-8706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1265984843Medicaid